an interprofessional education pilot program on screening, brief … · 2019-03-07 · treatment...

http://ijhe.sciedupress.com International Journal of Higher Education Vol. 8, No. 1; 2019

Published by Sciedu Press 119 ISSN 1927-6044 E-ISSN 1927-6052

An Interprofessional Education Pilot Program on Screening, Brief

Intervention, and Referral to Treatment (SBIRT) Improves Student

Knowledge, Skills, and Attitudes

Constance van Eeghen1, Juvena Hitt

1, John G. King

2, Jane E. Atieno Okech

3, Barbara Rouleau

4, Kelly Melekis

5,

Rodger Kessler6 & Richard Pinckney

7

1 General Internal Medicine-Research, Robert M. Larner MD College of Medicine, The University of Vermont, 89

Beaumont Avenue S456, Burlington, VT, USA

2 Department of Family Medicine, Robert M. Larner MD College of Medicine, The University of Vermont, 89


3 Department of Leadership and Developmental Sciences, College of Education & Social Services, The University of

Vermont, Mann Hall 101B, Burlington, VT, USA

4Department of Nursing, College of Nursing & Health Sciences, The University of Vermont, Burlington, VT, USA

5 Social Work Department, Skidmore College, 815 N. Broadway, Saratoga Springs, NY, USA

6 Behavioral Health Program, College of Healthcare Solutions, Arizona State University, Phoenix, AZ, USA

7 Department of Internal Medicine, Robert M. Larner MD College of Medicine, The University of Vermont, 89


Correspondence: Constance van Eeghen, General Internal Medicine Research, Robert M. Larner MD College of

Medicine, The University of Vermont, 89 Beaumont Avenue S456, Burlington, VT 05405, USA. E-mail:

[email protected]

Received: January 16, 2019 Accepted: February 12, 2019 Online Published: February 14, 2019

doi:10.5430/ijhe.v8n1p119 URL: https://doi.org/10.5430/ijhe.v8n1p119

Abstract

Background

Recent efforts to prepare healthcare professionals to care for patients/clients with substance use problems have

incorporated SBIRT (Screening, Brief Intervention, and Referral to Treatment) into graduate education programs.

This pilot study adds to the literature by examining the impact of an SBIRT interprofessional education approach for

behavioral health graduate students and medical residents as planned by faculty from multiple professions at a state

university. It measured changes in attitudes, abilities, skills, and knowledge in these interprofessionally trained

students.

Methods

Faculty in Counseling, Family Medicine, Internal Medicine, Nursing and Social Work departments collaborated to

develop an interprofessional curriculum delivered through a small-group and active learning approach.

Seventy-one residents and graduate students participated. Pre- and post-training surveys measured self-perceived

attitudes, abilities, and skills along with objectively measured knowledge. Analysis examined pre- to post-training

changes in scores.

Results

Pre-training surveys yielded an 89% response rate; post-training, 85%. Self-perceived attitudes did not change

significantly, except a 20% increase in how rewarded students felt while working with patients/clients with

alcohol/drug use disorders (P < .01). Compared to baseline, there was a statistically significant increase in all items

of self-perceived ability (P<.01) and all items of self-perceived communication skills (P=.04). Knowledge mean

scores also increased significantly (P < .001) across both primary care and behavioral health student groups.



Conclusions

Interprofessional training in SBIRT produced improvements in ability, skills, knowledge, and some attitudes. Such

programs may inform providers who care for patients/clients with substance use problems, improving their personal

experience and professional competence.

Keywords: motivational interviewing; substance-related disorders; interprofessional education; counseling

education; medical education; nursing education; social work education; curriculum

1. Introduction

Alcohol and drug use disorders affect morbidity and mortality across the globe. Annually, 3.3 million deaths

worldwide are attributed to alcohol use disorder (WHO, 2015). In the U.S., drug-related overdoses increased by 540%

between 1980 and 2010. The number of drug overdose deaths per year increased 23%, from 38 329 in 2010 to 47

055 in 2014 (Warner, Trinidad, Bastian, Minino, & Hedegaard, 2016). Screening, Brief Intervention, and Referral to

Treatment (SBIRT) is a “comprehensive, integrated, public health approach to the delivery of early intervention and

treatment services for adolescents and adults dealing with substance misuse (including use disorder) issues” (Babor

et al., 2007, p. 8). The SBIRT program serves the targeted substance users who are not yet dependent and could

reduce drug use through early intervention (Gryczynski et al., 2011; Madras et al., 2009). The SBIRT program has

been shown to reduce alcohol consumption and consequences of abuse (APHA, 2008).

1.1 Role of Interprofessional Education (IPE)

Health care professionals will need to provide SBIRT interventions in interdisciplinary settings (Agerwala &

McCance-Katz, 2012; Davoudi & Rawson, 2010) and on teams (Cleak & Williamson, 2007; Newhouse & Spring,

2010). Interprofessional education (IPE) can enhance SBIRT programs and benefit all learners training to work in

such contexts substantially. The Health and Medicine Division of the National Academies supports IPE-enhanced

training to improve patient/client outcomes through better utilization of the shrinking health care workforce

(Corrigan, 2005). Though graduate medical education programs have successfully trained residents in SBIRT, most

of the studied programs are not interprofessional. (Note 1)

1.2 IPE Literature

The terms “interdisciplinary” and “interprofessional” are often used interchangeably in the literature, but there are

substantial differences. “Interdisciplinary” has been defined as a branch of knowledge or field of study. Multiple

disciplines can be found within a single profession such as medical doctors with specialty disciplines in medicine,

pediatrics, psychiatry, dentistry, etc. (Bray et al., 2012; Neufeld et al., 2012; Pringle et al., 2012; Tetrault et al., 2012).

The term “interprofessional” relates to a vocation or profession requiring specialized knowledge and skills, such as

medicine, nursing, counseling and social work (IEC, 2011). Olenick, Allen, and Smego (Olenick, Allen, & Smego,

2010) report that interdisciplinary behavior lacks the depth of collaboration implied by the term “interprofessional.”

The World Health Organization (Gilbert, Yan, & Hoffman, 2010) defines IPE as “when students from two or more

professions learn about, from, and with each other to enable effective collaboration and improve health outcomes” (p.

196). Interprofessional education is increasingly included as a required component in university accreditation

standards for health professions in order to prepare a “collaborative practice-ready health workforce” (Gilbert et al.,

2010, p. 196). A collaborative practice-ready health worker is someone who has learned how to work in an

interprofessional team and is competent to do so. The Interprofessional Collaborative Expert Panel (2011) cited four

core competencies for Interprofessional Collaborative Practice. The four competency domains are: 1) Values and

Ethics; 2) Roles and Responsibilities; 3) Interprofessional Communication; 4) Teams and Teamwork.

Because collaboration between professions is critical to improving quality, safety, and access to care, providing

opportunities for interprofessional learning experiences can help prepare future professionals for a team approach to

providing care (Hackett, 2015). A growing number of studies suggest that IPE improves students’ confidence in their

professional role (Mann, 2009), attitudes toward and knowledge about other professions and toward IPE (Bolesta &

Chmil, 2014; Pelling, Kalen, Hammar, & Wahlstrom, 2011), and team and clinical reasoning skills (Robben et al.,

2012; Seif et al., 2014). Students who interact with other health professions learn to value diverse perspectives,

respect the knowledge and expertise of other professions, collaborate when problem-solving, and communicate as a

team to ensure patient safety (Olenick et al., 2010; Solomon & Salfi, 2011).

As a result of the need for IPE, a number of investigative educators have developed and studied interprofessional

training for students to better prepare them for the workforce (Duong, O'Sullivan, Satre, Soskin, & Satterfield, 2016;

A. M. Mitchell et al., 2018; Monteiro et al., 2017; Neander et al., 2018; Neft, 2018; Peterson, 2017). Collectively,



these programs have demonstrated that interprofessional trainings have high satisfaction among students and enhance

interprofessional competence, condition specific knowledge, skill, and attitudes around SBIRT and working with

patients with substance use disorders. However, these interprofessional SBIRT programs have differed extensively in

the degree to which the students interacted, how much the students represent the true composition of professionals

doing this work, and the degree to which faculty role modeled interprofessional collaboration.

When reviewing the research to date, a pattern emerges of a possibly optimal intervention: synchronous, face-to-face

training, in which interprofessional students from all appropriate disciplines work together, using standardized

patients that represent complex real-world scenarios (e.g. patients have interacting substance use disorders (SUD)

and chronic medical conditions), and fully interprofessional faculty who role-model collaboration as part of

instruction. There is one study that possesses all of these attributes. Peterson, Brommelsiek, and Amelung (Peterson,

2017) trained a cohort of learners which included students of advanced practice nursing, pharmacy, clinical

psychology, and social work. They found that students in this program valued the team approach and experienced

high levels of communication, cooperation, and collaboration during the training. What is unknown is whether this

training enhanced student attitudes, skills, or knowledge. An interactive IPE curriculum showing measurable results

in supporting a collaborative workforce that is knowledgeable, skilled, and confident in its practice of SBIRT would

help fill this gap in the field.

1.3 Purpose of Study

The University of Vermont (UVM) SBIRT Training Collaborative piloted an interprofessional curriculum that builds

on this work by training a similar group of students (counseling, medical residents, nursing, and social work) using a

similar approach and evaluating the impact of this training on student attitudes, abilities, skills, and knowledge.

Faculty who developed and delivered the program represented all of the four professions. The program began with a

brief didactic session at program level, followed by two 2-hour workshops which included an interprofessional

faculty panel, standardized patients, and small interprofessional group work. The faculty panel provided role

modeling and discussion of various contexts for SBIRT. The standardized patients engaged students in practicing

brief negotiated interviews and the small groups allowed students to learn from each other about referring

patients/clients and working as a team. The theme of learning from other professions and the importance of clinical

context for applying SBIRT permeated all elements of the training. We further advanced this field by observing

differences among medical and behavioral health service students in their response to this training. This work was

supported by the Substance Abuse and Mental Health Service Agency (SAMHSA) 2014-2017.

2. Methods

2.1 Procedures

To pilot this work, the interprofessional SBIRT Advisory Council oversaw the development of the interprofessional

education SBIRT curriculum, beginning in 2013. This council included representation from five departments

(Counseling, Family Medicine, Internal Medicine, Nursing, and Social Work) in three UVM colleges (Education and

Social Services, Nursing and Health Sciences, and Medicine). The Council endorsed the four domains of IPE core

competencies (Table 1) and imbedded the curricula into each discipline except Social Work, in which participation in

the SBIRT program was voluntary. Using a flipped-classroom model, most students completed an online didactic

training which was then followed by a series of two 2-hour interprofessional workshops. The workshops occurred

approximately 1 month apart. Using videos and role-playing exercises with standardized patients, students learned

screening for risky substance use, communication styles and strategies for brief intervention based on a brief

motivational interviewing approach, and referral collaboration methods. Training in brief negotiated interviews

followed recommendations of the Motivational Interviewing Network of Trainers (MINT) (2016). A MINT faculty

member served on the SBIRT Advisory Council and contributed to the development of the training program. A faculty

development workshop preceded the training at which faculty from all departments were engaged in a review of the

workshop content and teaching methods.

2.2 Training site and Students

The University of Vermont’s Simulation Laboratory provided real time, practical experience to support SBIRT and

team-building skills. The nine-month training program engaged first-year residents and first- or second-year

graduate students in counseling, nursing, and social work (Table 2). The Committees on Human Research at UVM

reviewed the study protocol and determined that that it did not require IRB review under 45 CFR 46.102(d).



Table 1. Interprofessional Education Domains and Core Competencies included in training program

Values/Ethics

Patient-centered care planning

Mutual respect for other professions

Act with dignity and integrity

Roles/Responsibilities

Recognize one’s limitations in skills, knowledge and abilities

Engage diverse professionals to complement one’s own expertise

Use unique and complementary abilities of all members of the team

Interprofessional Communication

Confident expression of one’s knowledge and opinions

Listen actively

Encourage ideas and opinions of others

Give timely, sensitive, instructive feedback

Teams/Teamwork

Engage and integrate other professionals in patient-centered care

Share accountability

Reflect on team performance

As shown in Table 1, four interprofessional competency domains as published by The Interprofessional Education

Collaborative (2011) can guide training initiatives.

Table 2. Professions and demographic characteristics of the 67 SBIRT student respondents at the University of

Vermont, (Spring 2015)

Profession N

Total 67*

Counseling (%) 12 (18)

Family Medicine 4 (6)

Internal Medicine 12 (18)

Social Work 17 (25)

Nursing 22 (33)

Demographics (%) **

Female 49 (73)

Hispanic/Latino 3 (4)

Black/African American 1 (1)

Asian 3 (4)

White 57 (85)

American Indian 1 (1)

Not Reported 7 (10)

* 4 students did not complete either a pre-training or a post-training survey

** Total sums for race total > 67 as respondents chose all that applied

As shown in Table 2, students who completed surveys both before and after the training program represented all

professions involved in this project, as well as an array of demographic characteristics.



2.3 Didactic Education Program

Students from each department received uniform didactic education using the SAMHSA SBIRT curriculum.

Didactic curriculum (85 minutes plus optional videos) provided by SAMSHA via an Oregon Health and Science

University website (http://www.sbirtoregon.org), or through in-person interprofessional instruction (2 hours)

developed at our institution, provided basic information on alcohol and drug use, prevalence, morbidity and

interventions, and screening workflows/tools for adolescents and adults. Those receiving in-person interprofessional

instruction were exposed to the same content as other students; however, it was delivered in a two-hour, small group

session which featured didactics, a demo, and discussion. This session was taught by a member of MINT.

2.4 Interprofessional Session 1

The first in-person IPE session provided a faculty panel discussion, motivational interviewing (MI) demonstration,

team-based training with standardized patients, and debriefing with faculty and program staff. The goal of this 2-hour

session was to increase student skills in applying SBIRT to clinical scenarios. Objectives included:

1. Understand the different clinical contexts in which SBIRT can be used

2. Interpret the results of screening tools

3. Conduct a brief negotiated interview

4. Examine the role of diversity in the interview and intervention process

5. Explore each other’s professional roles and responsibilities through IPE

Faculty panel discussions presented varying contexts in which disciplines may screen for substance use and utilize MI

skills. A representative from each profession discussed 1) their training in SUD, 2) work settings and types of routine

screening/assessments appropriate for SBIRT, 3) scenarios that prompt screening for SUD, 4) common barriers to

SBIRT, and 5) situations particularly assisted by interprofessional collaboration. Following the panel, students

observed a demonstration of a brief negotiated interview and asked questions about MI skills and strategies.

Faculty-facilitated interprofessional groups of 5-8 students, randomly assigned, engaged in active learning with trained

standardized patients (SPs) enacting three substance misuse scenarios in 15-minute segments. Students prepared by

reviewing handouts with a patient/client profile, case description, and results of pre-screening tools for alcohol and

drug misuse (Gache et al., 2005; Yudko, Lozhkina, & Fouts). In small groups, students collaborated to gather relevant

history including detailed substance misuse screening. They practiced brief negotiated interviews as indicated by the

case. Following each interview, a faculty member debriefed students and SPs, reviewing interview strengths and

alternative strategies as well as encouraging discussion of approaches used by different professions. Facilitators helped

students consider all aspects of the case (medical, psychosocial, etc.), work as an interprofessional team, respect each

other’s professions and scope of practice, and demonstrate awareness and respect for cultural/identity differences for

each patient/client.

2.5 Interprofessional Session 2

The second 2-hour interprofessional session focused on “referral to treatment” through a faculty panel discussion,

review of cases from session one, and debriefing. The goal was to provide insight to the individualized needs of

patients/clients regarding substance misuse and approaches to meet those needs through an interprofessional team.

Objectives included:

1. Demonstrate an understanding of the roles of various professions in the management of SUD

2. Explain the reasons for initiating a referral for patients/clients in each setting

3. Consider a range of factors in making referrals to other professionals

During panel discussion, faculty discussed contextual and discipline-specific factors in making referrals. A

representative from each profession discussed 1) the referral process in relation to their profession, 2) common

hurdles, 3) strategies for a successful referral, e.g. “warm handoff,” and 4) approaches to a comprehensive care plan

including treatment from other providers/specialists. Materials included guidelines for referral-to-treatment and

resources for additional training. Students joined interprofessional active learning groups of 4-6 students to revisit

the cases from session one, focusing on strategies for advancing the initial intervention. (Note that group sizes were

adjusted between sessions to accommodate the number of faculty volunteers and students present.) Using these

strategies, students planned referrals and evaluated their benefits in addressing SUD. The faculty facilitators were

encouraged to explore the role of different professionals in intervening with SUD cases and how they can work

http://www.sbirtoregon.org/



together as a team to address patient needs. During debrief, faculty and students addressed questions about the

process of referral and how to continue to use and develop SBIRT skills.

2.6 Survey Methods

We measured student satisfaction with each session using SAMSHA’s GPRA survey (SAMHSA, 2017) immediately

following the session. Pre/post surveys assessed changes in attitudes, abilities, skills, and knowledge of working

with patients/clients with drug or alcohol misuse. Students also accessed pre-training surveys through REDCap, a

secure, web-based application hosted at UVM. (Note 2) Post-training, students received paper surveys at their

training sites.

2.7 Questionnaire Development

We constructed a pre and post survey that measured attitudes, abilities, and skills based on previous work of SBIRT

training programs at the University of Pittsburgh (Venkat et al., 2017). From the original items and domains, we

selected those representing the domains of attitudes, abilities, and skills. All assessment items used a 5-point Likert

scale. “Attitudes” included items that reflected an underlying belief system about working with patients/clients with

use disorders. “Abilities” reflected overall perception of knowledge, skill, and experience. “Skills” isolated the

communications skills, e.g. to raise the topic of quantity/frequency of alcohol or other drug use and ask the patient to

self-assess.

In addition, we developed a 32-item test of SBIRT facts for pre/post comparisons of students’ knowledge. The test

presented questions in “multiple choice single best answer” format or “check all that apply.” The latter were

analyzed dichotomously, as individual items for each possible response. The test contained questions based on

didactic content, including the effects of drugs/alcohol, screening strategies, and brief negotiated interventions. The

complete survey of “attitudes, abilities, and skills” and “student knowledge” is available as Supplemental Digital

Appendix 1. The survey was administered twice (pre/post) in the second year of the program, from 2014-2015.

2.8 Analysis

We analyzed the Likert scale items for attitudes, abilities, and skills by subtracting pre-training from post-training

scores and conducting one-sample testing with a comparison to a null of 0, or no difference. We used a t-test when

assumptions of normality were met and the sign-rank test as a non-parametric alternative. To summarize our

findings, we dichotomized the Likert scale by presenting the proportion of participants agreeing with competence

and attitudinal statements (scores of 4 or 5).

Similarly, we analyzed knowledge scores by comparing differences between pre- and post-training scores,

comparing to a null of 0, and assessing for statistical significance using either one-sample t-test or sign rank tests as

appropriate. We conducted subgroup analysis by grouping students into behavioral health (BH) practitioners

(counseling and social work) and primary care (PC) practitioners (family practice, internal medicine and nursing).

All testing was two-tailed with ∝ = .05, using STATA 12.0 (StataCorp, Stata. 2011, StataCorp LP: College Station,

TX).

3. Results

3.1 Students

A total of 71 students completed the training in the course of an academic year, each assigned to one of three IPE

sections, with 67 completing one or both surveys. Sixty-three students (28 BH and 35 PC) completed the pre-training

survey (89% response rate) and sixty (25 BH and 35 PC) completed the post-training survey (85%). Fifty-five

students completed both sets of evaluation and are included in the analyses. Student satisfaction was high. After

session one, 89.6% of students were satisfied with the overall quality and 86.6% would recommend the training to a

colleague. Students were similarly satisfied with session two; 88.1% were satisfied with the overall quality of and

86.6% would recommend the training to a colleague. There were no significant differences between behavioral

health and primary care trainees in these satisfaction ratings.

3.2 Self-Perceived Attitudes

Most self-perceived attitudes did not change significantly with the exception of two items showing a significant

increase in students’ perceptions that working with patients/clients with alcohol or SUD was rewarding. Before

training, 41% of students agreed that working with patients/clients with alcohol use disorder was rewarding;

afterwards, 61% agreed, P =.04. The findings for substance use disorder were similar (Figure 1). Both PC students

and BH students experienced this boost. However, the two student subgroups were significantly different from each

other, before and after training. Pre-training, 54% of BH students agreed that working with those with alcohol use



disorder was rewarding while only 30% of PC clinicians agreed, P =.04. Post-training, agreement increased to 79%

in the BH students and 47% in the PC students, P <.01. Changes seen in drug use disorders were similar, with an

increase from 35% to 59% in students who found working with drug use disorders rewarding, P <.01. At baseline the

two student groups differed, with 50% of BH students and 23% of PC clinicians finding this rewarding, P <.01.

Post-training, 79% of BH students and 43% of PC clinicians found working with drug use disorders rewarding, P

<.01.

Figure 1. Changes in Self-Perceived Attitudes

Legend: Compares pre-course attitudes of 55 students at the University of Vermont to post-course average scores in

Spring 2015. P values indicated only when less than or equal to 0.05.

3.3 Self -Perceived Ability (Knowledge, Skills, Experience)

All measures of self-perceived ability increased after training (Figure 2). For example, only 44% of students felt they

could appropriately advise patients/clients about the effects of drugs prior to the workshop, which increased to 70%

after the workshop, P <.01. At baseline, the lowest rated ability (working with people with drug misuse) found 19%

of students satisfied. Post-training, this increased to 52%, P <.01. Interestingly, these baseline and post-workshop

rating changes were exactly equal in BH and PC clinicians.



Figure 2. Changes in Self-Perceived Ability

Legend: Compares pre-course ability of 55 students at the University of Vermont to post-course average scores in

Spring 2015. P values indicated only when less than or equal to 0.05.

3.4 Self-Perceived Communication Skills

We found statistically significant improvements in all five measures of self-perceived communication skills

competence (Figure 3), with at least 80% of students feeling competent post-training. The most striking

improvements in feeling competent included asking about behavioral health change (rising from 35% before training

to 85% after, P <.01) and asking about client/patient need to change their use (increasing from 54% to 80%, P

=.002).

0 10 20 30 40 50 60 70 80 90 100

I feel as though I have a working knowledge ofproblems related to alcohol misuse. (Agreement)

I feel I can appropriately advise my clients/patientsabout the effects of alcohol misuse.(Agreement)

On the whole, I am satisfied with the way I workwith people who have problems with alcohol

misuse.(Agreement)

I feel as though I have a working knowledge orproblems related to drug misuse.(Agreement)

I feel I can appropriately advise my clients/patientsabout the effects of drug misuse.(Agreement)

On the whole, I am satisfied with the way I workwith people who have problems with drug

misuse.(Agreement)

Baseline Post-course

P < 0.01

P < 0.01

P < 0.01

P < 0.01

P < 0.01

P < 0.01



Figure 3. Changes in Self-Perceived Communication Skills Competence

Legend: Compares pre-course communication skills of 55 students at the University of Vermont to post-course

average scores in Spring 2015. P values indicated only when less than or equal to 0.05.

Differences between student types appeared only regarding competence in “asking clients about alcohol and drug

use.” Pre-training, 75% of BH students felt competent compared to 90% of PC students, P = .01. BH students

responded more strongly to training, P =.01, resulting in no significant difference between the two groups

post-training.

3.5 Test Score Knowledge

Based on test scores, students’ knowledge changed significantly. The “knowledge” mean score increased from 27 to

28 points out of a possible 32, (interquartile range for change 0-3) P <.001. Primary Care students had slightly higher

knowledge pre-training scores (mean (SD) = 28.1 (1.6)) than those for BH students (25.8 (2.7)). There was not a

statistically significant difference between PC and BH students on the change in knowledge but the two groups

remained significantly different in their final scores with an average of 28.9 points for PC providers and 27 for BH

providers, P=.008. The standardized mean difference in scores was 0.53 (Lakens, 2013).

4. Discussion

A comprehensive IPE-based SBIRT curriculum was feasible and produced a successful approach to educating health

care professionals. The curriculum included a self-paced introductory session delivered primarily online prior to

face-to-face work groups. Two 2-hour interprofessional sessions with expert faculty provided students with

practice opportunities and discussions focused on SBIRT methodology and individualized patient/client treatment

planning. This curriculum allowed faculty and students across multiple professions to work together and learn from

each other. The findings of this study reinforced literature recommendations that effectively addressing substance use

in clinical practice calls for interprofessional teams and settings (Agerwala & McCance-Katz, 2012; Cleak &

Williamson, 2007; Davoudi & Rawson, 2010; Newhouse & Spring, 2010). The success of this pilot resulted in a

0 20 40 60 80 100

Ask clients/patients about alcohol and druguse.

Asking about quantity and frequency ofalcohol or other drug use.

Ask clients/patients if they see theirsubstance use as a problem as determined

by patient/client need.

Ask clients/patients if they think that there isa need to change their alcohol and drug use

as determined by patient/client need.

Discuss change with clients/patientsregarding their alcohol or drug use behavior

as determined by patient/client need.

Baseline Post-course

P < 0.01

P < 0.01

P < 0.01

P < 0.01

P = .048



formal decision by the various departments at the University of Vermont to continue the program beyond the funding

of the grant; the program is currently in its fifth year.

One interesting finding is that while knowledge, abilities, and skills seemed to improve, attitudes were less

influenced by the training. Only two of the attitudinal measures showed improvement as a result of the training. One

explanation is that attitudes may be harder to change in response to a training of this type. Also, some of the baseline

items related to attitude were already high at baseline. Six of the eight attitudes measures had 60% or higher

agreement at baseline, making it harder to improve.

Some interesting differences emerged between behavioral health students (social work and counseling) compared to

the primary care students (nursing students and residents). The primary care providers had higher baseline and post

workshop scores on knowledge. This is likely because this represents a post-graduate primary care audience with

several years of clinical experience compared to the mostly first-year behavioral health masters students. A similar

pattern was seen at baseline in feeling competent to ask clients about alcohol and drug use. The behavioral health

providers felt less competent than the primary care providers. This may be due to the regular inclusion of alcohol and

drug use assessment in the PC role, whereas this responsibility is not a usual function of a BH practitioner unless

specializing in substance use treatment. In this case, the training actually improved the behavioral health provider’s

competence so much that there was no significant difference between the two groups by the end of the training. What

was also reassuring to see is that both groups expressed equally high satisfaction with the training.

Our program adds to the growing evidence that education about SBIRT can and perhaps should be offered in an IPE

curriculum that fosters team-based care. Building on previous studies, we demonstrated that bringing an

interprofessional cohort of students together with an interprofessional, collaborative team of faculty produced

significant changes in outcome as measured by attitude, ability, skills, and knowledge. The approach should enhance

the ability of teams trained through this method to provide effective substance use screening and interventions.

Furthermore, this team-based program can embrace medical conditions as they relate to behavioral and SU

conditions.

4.1 Limitations

Limitations include an absence of a control group to measure secular trends. This was the only known SUD

education for these students during this period; we presumed that changes seen were the direct result of training.

Trainees may have had varied education about or experience with SUD beforehand or concurrently, affecting

differences in outcomes. Perceptual measures were based on self-report, not observation, with no follow-up

assessment of skills and attitudes to reflect retention. The data represent one trainee cohort with limited sample size

and statistical power. The survey return rate was 89% prior to training, 85% after. While acceptable for this type of

research, responses may be systematically different from those who did not complete the surveys, a possible bias.

Finally, our evaluation did not capture measures specifically meant to reflect the interprofessional education program.

Demonstrating high satisfaction and self-perceived improvements was an important first step. Future work should

establish how this influences students’ perceptions of working with other professions as well as whether this method

of instruction leads to greater learning than the traditional “within profession” approach to training. Next steps

should also include examination of potential differences between those for whom this training is/was their sole

exposure compared with those with either prior and/or concurrent training (e.g., enrolled in elective course,

placement/internship at alcohol/drug use treatment facility, etc.)

4.2 Strengths

Our research has important strengths. This is the first report we know of piloting the implementation in an

academic setting of SBIRT curriculum on substance use (SU) conditions that included all medical and behavioral

students in one cohort under a single, collaborative, interprofessional faculty team. The findings were significantly

positive and are generalizable to other settings where training is focused on increasing readiness for collaborative

health care using evidence-based interventions in team-based care.

Major findings of this study have implications for future training of a sustainable, high-value workforce. To

respond to the significant negative impact of SU conditions, health care professionals need to feel rewarded by

working with this patient/client population. Although BH students showed less baseline negative bias toward

patients/clients with SU conditions, all trainees found an improved sense of satisfaction with caring for these

patients/clients and a reduced sense of helplessness in addressing their problems. These findings, especially

amongst PC trainees, may significantly reduce provider burnout (Ratanawongsa et al., 2008) and lead to a



compelling new hypothesis: interprofessional education may improve both patient/client care and provider

experience.

5. Conclusions

An IPE program on SBIRT including didactic and interactive practice sessions can improve student knowledge,

skills, and attitudes through a practical addition to curricula using self-directed and brief instruction. Future research

considerations include comparing intraprofessional education to interprofessional education on the outcomes

measured. Key variables to add to this work include knowledge and mutual respect gained during training about

other professionals, the impact of the program on future care and outcomes of patients/clients with SUD, and

capacity for workforce development for the care of populations with these conditions. Data on provider’s change of

practice, perceptions of cultural competence with SUD, patient/client perspectives of SBIRT, and their success in

changing behavior due to SBIRT would also be valuable. As the SBIRT Advisory Council continues, we plan to

continue to measure the benefit of this SBIRT training approach, evaluating the domains of IPE. Programs similar

to this one may provide a strategy to sustain the primary care workforce and improve competence in care delivery for

patients/clients with SUDs.

Acknowledgments

The authors wish to thank the other members of the University of Vermont SBIRT Advisory Council:

Carol Buck-Rolland, EdD

Rosemary Dale, EdD

Willow Stein, MSW

Jon van Luling, BA

Gary Widrick, PhD

And also, the leadership of the UVM Clinical Simulation Laboratory:

Cate Nicholas, EdD, MS, PA

Robert Bolyard

And the Director of the Teaching Academy at the University of Vermont:

Kathryn Huggett, PhD, Director, The Teaching Academy at the Larner College of Medicine

Funding/Support

SAMHSA

Grantee Federal Identification Number: 1U79TI025395-01

Name of Institution awarded Grant: University of Vermont

Project Name: UVM SBIRT Training Collaborative

The funder provided oversight and technical support during the course of this project but was not involved in the

composition of the manuscript.

Note: Dr. Barbara Rouleau passed away unexpectedly in 2017. Although she contributed significantly to the

manuscript, she did not approve its final submission.

References

Agerwala, S. M., & McCance-Katz, E. F. (2012). Integrating screening, brief intervention, and referral to treatment

(SBIRT) into clinical practice settings: a brief review. J Psychoactive Drugs, 44(4), 307-317.

https://doi.org/10.1080/02791072.2012.720169

APHA. (2008). Alcohol screening and brief intervention: A guide for public health practitioners. Retrieved from

Washington, DC. https://doi.org/10.1300/J465v28n03_03

Babor, T. F., McRee, B. G., Kassebaum, P. A., Grimaldi, P. L., Ahmed, K., & Bray, J. (2007). Screening, Brief

Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of

substance abuse. Subst Abus, 28(3), 8. https://doi.org/10.1300/J465v28n03_03

Bernstein, E., Bernstein, J., Feldman, J., Fernandez, W., Hagan, M., Mitchell, P., . . . Owens, P. (2007). An evidence

based alcohol screening, brief intervention and referral to treatment (SBIRT) curriculum for emergency

https://doi.org/10.1080/02791072.2012.720169

https://doi.org/10.1300/J465v28n03_03

https://doi.org/10.1300/J465v28n03_03



department (ED) providers improves skills and utilization. Subst Abus, 28(4), 79-92.

https://doi.org/10.1300/J465v28n04_01

Bolesta, S., & Chmil, J. V. (2014). Interprofessional education among student health professionals using human

patient simulation. Am J Pharm Educ, 78(5), 94. https://doi.org/10.5688/ajpe78594

Bray, J. H., Kowalchuk, A., Waters, V., Laufman, L., & Shilling, E. H. (2012). Baylor SBIRT Medical Residency

Training Program: model description and initial evaluation. Subst Abus, 33(3), 231-240.

https://doi.org/10.1080/08897077.2011.640160

Cleak, H., & Williamson, D. (2007). Preparing health science students for interdisciplinary professional practice. J

Allied Health, 36(3), 141-149.

Corrigan, J. M. (2005). Crossing the quality chasm: A New Engineering/Health Care Partnership. Washington (DC):

National Academies Press (US).

Davoudi, M., & Rawson, R. A. (2010). Screening, brief intervention, and referral to treatment (SBIRT) initiatives in

California: notable trends, challenges, and recommendations. J Psychoactive Drugs, Suppl 6, 239-248.

https://doi.org/10.1080/02791072.2010.10400547

Duong, D. K., O'Sullivan, P. S., Satre, D. D., Soskin, P., & Satterfield, J. (2016). Social Workers as

Workplace-Based Instructors of Alcohol and Drug Screening, Brief Intervention, and Referral to Treatment

(SBIRT) for Emergency Medicine Residents. Teaching and Learning in Medicine, 28(3), 303-313.

https://doi.org/10.1080/10401334.2016.1164049

Gache, P., Michaud, P., Landry, U., Accietto, C., Arfaoui, S., Wenger, O., & Daeppen, J.-B. (2005). The Alcohol

Use Disorders Identification Test (AUDIT) as a Screening Tool for Excessive Drinking in Primary Care:

Reliability and Validity of a French Version. Alcoholism: Clinical and Experimental Research, 29(11),

2001-2007. https://doi.org/10.1097/01.alc.0000187034.58955.64

Gilbert, J. H., Yan, J., & Hoffman, S. J. (2010). A WHO report: framework for action on interprofessional education

and collaborative practice. J Allied Health, 39 Suppl 1, 196-197.

Gryczynski, J., Mitchell, S. G., Peterson, T. R., Gonzales, A., Moseley, A., & Schwartz, R. P. (2011). The

relationship between services delivered and substance use outcomes in New Mexico's Screening, Brief

Intervention, Referral and Treatment (SBIRT) Initiative. Drug and Alcohol Dependence, 118(2–3), 152-157.

doi:https://doi.org/10.1016/j.drugalcdep.2011.03.012

Hackett, A., Rhodes, D, Cox, C. (2015). Attitudes toward Healthcare Teamwork between Osteopathic Medical

Students in an Interprofessional or Intraprofessional Clinical Education Program. Health and Interprofessional

Practice, 2(3), eP1072. doi:https://doi.org/10.7710/2159-1253.1072

IEC. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Retrieved

from Washington, D.C. https://doi.org/10.3389/fpsyg.2013.00863

Lakens, D. (2013). Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests

and ANOVAs. Frontiers in Psychology, 4(863). doi:10.3389/fpsyg.2013.00863

Madras, B. K., Compton, W. M., Avula, D., Stegbauer, T., Stein, J. B., & Clark, H. W. (2009). Screening, brief

interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites:

Comparison at intake and 6 months later. Drug and Alcohol Dependence, 99(1–3), 280-295.

https://doi.org/10.1016/j.drugalcdep.2008.08.003

Malone, G. P., Vale Arismendez, S., Schneegans Warzinski, S., Amodei, N., Burge, S. K., Wathen, P. I., . . .

Williams, J. F. (2015). South Texas Residency Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Training: 12-Month Outcomes. Subst Abus, 36(3), 272-280. https://doi.org/10.1080/08897077.2014.988839

Mann, K., Sargeant, J., & Hill, T. . (2009). Knowledge translation into interprofessional education: What difference

does interprofessional education make to practice? . Learning in Health and Social Care, 8(3), 154-164.

https://doi.org/10.1111/j.1473-6861.2008.00207.x

Marshall, V. J., McLaurin-Jones, T. L., Kalu, N., Kwagyan, J., Scott, D. M., Cain, G., . . . Taylor, R. E. (2012).

Screening, brief intervention, and referral to treatment: public health training for primary care. Am J Public

Health, 102(8), e30-36. https://doi.org/10.2105/AJPH.2012.300802

https://doi.org/10.1300/J465v28n04_01

https://doi.org/10.5688/ajpe78594

https://doi.org/10.1080/08897077.2011.640160

https://doi.org/10.1080/10401334.2016.1164049

https://doi.org/10.1097/01.alc.0000187034.58955.64

https://doi.org/10.3389/fpsyg.2013.00863

https://doi.org/10.1080/08897077.2014.988839

https://doi.org/10.2105/AJPH.2012.300802



MINT. (2016). MINT: Excellence in Motivational Interviewing. MINT: Excellence in Motivational Interviewing.

Retrieved from http://www.motivationalinterviewing.org/

Mitchell, A. M., Riccelli, A., Boucek, L., Puskar, K. R., Hagle, H., & Lindsay, D. (2018). Effect on Dental Hygiene

Students of a Substance Use Simulation Conducted with Nursing Students. Journal of Dental Education, 82(5),

469-474. https://doi.org/10.21815/JDE.018.052

Mitchell, M. A., Broyles, L. M., Pringle, J. L., Kraemer, K. L., Childers, J. W., Buranosky, R. A., & Gordon, A. J.

(2017). Education for the mind and the heart? Changing residents' attitudes about addressing unhealthy alcohol

use. Subst Abus, 38(1), 40-42. https://doi.org/10.1080/08897077.2016.1185076

Monteiro, K., Dumenco, L., Collins, S., Bratberg, J., MacDonnell, C., Jacobson, A., . . . George, P. (2017). An

interprofessional education workshop to develop health professional student opioid misuse knowledge, attitudes,

and skills. Journal of the American Pharmacists Association, 57(2), S113-S117.

https://doi.org/10.1016/j.japh.2016.12.069

Neander, L. L., Hanson, B. L., Edwards, A. E., Shercliffe, R., Cattrell, E., Barnett, J. D., . . . King, D. K. (2018).

Teaching SBIRT through simulation: Educational case studies from nursing, psychology, social work, and

medical residency programs. 13, 39-47. https://doi.org/10.1016/j.xjep.2018.08.002

Neft, M. W., Mitchell, A.M., Puskar, K. (2018). Interprofessional education for teaching screening, brief intervention,

and referral to treatment (SBIRT) for substance use. Journal of Interprofessional Education and Practice, 10,

12-14. https://doi.org/10.1016/j.xjep.2017.10.004

Neufeld, K. J., Alvanzo, A., King, V. L., Feldman, L., Hsu, J. H., Rastegar, D. A., . . . MacKinnon, D. F. (2012). A

collaborative approach to teaching medical students how to screen, intervene, and treat substance use disorders.

Subst Abus, 33(3), 286-291. https://doi.org/10.1080/08897077.2011.640090

Newhouse, R. P., & Spring, B. (2010). Interdisciplinary evidence-based practice: moving from silos to synergy. Nurs

Outlook, 58(6), 309-317. https://doi.org/10.1016/j.outlook.2010.09.001

Olenick, M., Allen, L. R., & Smego, R. A., Jr. (2010). Interprofessional education: a concept analysis. Adv Med Educ

Pract, 1, 75-84. https://doi.org/10.2147/AMEP.S13207

Pelling, S., Kalen, A., Hammar, M., & Wahlstrom, O. (2011). Preparation for becoming members of health care

teams: findings from a 5-year evaluation of a student interprofessional training ward. J Interprof Care, 25(5),

328-332. https://doi.org/10.3109/13561820.2011.578222

Peterson, J., Brommelsiek, M., Amelung, S.K. (2017). An interprofessional education project to address veteran’s

healthcare needs. International Journal of Higher Education, 6, 1-16. https://doi.org/10.5430/ijhe.v6n1p1

Pringle, J. L., Kearney, S. M., Rickard-Aasen, S., Campopiano, M. M., & Gordon, A. J. (2017). A statewide

screening, brief intervention, and referral to treatment (SBIRT) curriculum for medical residents: Differential

implementation strategies in heterogeneous medical residency programs. Subst Abus, 38(2), 161-167.

https://doi.org/10.1080/08897077.2017.1288195

Pringle, J. L., Melczak, M., Johnjulio, W., Campopiano, M., Gordon, A. J., & Costlow, M. (2012). Pennsylvania

SBIRT Medical and Residency Training: developing, implementing, and evaluating an evidenced-based

program. Subst Abus, 33(3), 292-297. https://doi.org/10.1080/08897077.2011.640091

Puskar, K., Gotham, H. J., Terhorst, L., Hagle, H., Mitchell, A. M., Braxter, B., . . . Burns, H. K. (2013). Effects of

Screening, Brief Intervention, and Referral to Treatment (SBIRT) education and training on nursing students'

attitudes toward working with patients who use alcohol and drugs. Subst Abus, 34(2), 122-128.

https://doi.org/10.1080/08897077.2012.715621

Ratanawongsa, N., Roter, D., Beach, M. C., Laird, S. L., Larson, S. M., Carson, K. A., & Cooper, L. A. (2008).

Physician Burnout and Patient-Physician Communication During Primary Care Encounters. Journal of General

Internal Medicine, 23(10), 1581-1588. https://doi.org/10.1007/s11606-008-0702-1

Robben, S., Perry, M., van Nieuwenhuijzen, L., van Achterberg, T., Rikkert, M. O., Schers, H., . . . Melis, R. (2012).

Impact of interprofessional education on collaboration attitudes, skills, and behavior among primary care

professionals. J Contin Educ Health Prof, 32(3), 196-204. https://doi.org/10.1002/chp.21145

SAMHSA. (2017). CSAT GPRA Modernization Act Data Collection Tools. Retrieved from

https://www.samhsa.gov/grants/gpra-measurement-tools/csat-gpra

https://doi.org/10.21815/JDE.018.052

https://doi.org/10.1080/08897077.2016.1185076

https://doi.org/10.1016/j.japh.2016.12.069

https://doi.org/10.1016/j.xjep.2018.08.002

https://doi.org/10.1080/08897077.2011.640090

https://doi.org/10.1016/j.outlook.2010.09.001

https://doi.org/10.2147/AMEP.S13207

https://doi.org/10.3109/13561820.2011.578222

https://doi.org/10.1080/08897077.2017.1288195

https://doi.org/10.1080/08897077.2011.640091

https://doi.org/10.1080/08897077.2012.715621

https://doi.org/10.1007/s11606-008-0702-1

https://doi.org/10.1002/chp.21145



Satterfield, J. M., O'Sullivan, P., Satre, D. D., Tsoh, J. Y., Batki, S. L., Julian, K., . . . Wamsley, M. (2012). Using

standardized patients to evaluate screening, brief intervention, and referral to treatment (SBIRT) knowledge and

skill acquisition for internal medicine residents. Subst Abus, 33(3), 303-307.

https://doi.org/10.1080/08897077.2011.640103

Scott, D. M., McLaurin-Jones, T., Brown, F. D., Newton, R., Marshall, V. J., Kalu, N., . . . Taylor, R. E. (2012).

Institutional incorporation of screening, brief intervention, and referral to treatment (SBIRT) in residency

training: achieving a sustainable curriculum. Subst Abus, 33(3), 308-311.

https://doi.org/10.1080/08897077.2011.640135

Seale, J. P., Velasquez, M. M., Johnson, J. A., Shellenberger, S., von Sternberg, K., Dodrill, C., . . . Grace, D. (2012).

Skills-based residency training in alcohol screening and brief intervention: results from the Georgia-Texas

"Improving Brief Intervention" Project. Subst Abus, 33(3), 261-271.

https://doi.org/10.1080/08897077.2011.640187

Seif, G., Coker-Bolt, P., Kraft, S., Gonsalves, W., Simpson, K., & Johnson, E. (2014). The development of clinical

reasoning and interprofessional behaviors: service-learning at a student-run free clinic. J Interprof Care, 28(6),

559-564. https://doi.org/10.3109/13561820.2014.921899

Solomon, P., & Salfi, J. (2011). Evaluation of an interprofessional education communication skills initiative. Educ

Health (Abingdon), 24(2), 616.

Stanton, M. R., Atherton, W. L., Toriello, P. J., & Hodgson, J. L. (2012). Implementation of a "learner-driven"

curriculum: an screening, brief intervention, and referral to treatment (SBIRT) interdisciplinary primary care

model. Subst Abus, 33(3), 312-315. https://doi.org/10.1080/08897077.2011.640140

Tetrault, J. M., Green, M. L., Martino, S., Thung, S. F., Degutis, L. C., Ryan, S. A., . . . D'Onofrio, G. (2012).

Developing and implementing a multispecialty graduate medical education curriculum on Screening, Brief

Intervention, and Referral to Treatment (SBIRT). Subst Abus, 33(2), 168-181.

https://doi.org/10.1080/08897077.2011.640220

Venkat, A., Aldrige, A., Kearney, S. M., Radack, J., Rickard-Assen, S., Grasso, K., . . . Pringle, J. (2017). Derivation

of a Shortened Research Instrument for Measuring Alcohol and Other Drug (AOD) Attitudes in a Screening,

Brief Intervention, and Referral to Treatment (SBIRT) Training Program. Journal of Science, Humanities and

Arts, 4(2). https://doi.org/10.17160/josha.4.2.290

Warner, M., Trinidad, J. P., Bastian, B. A., Minino, A. M., & Hedegaard, H. (2016). Drugs Most Frequently

Involved in Drug Overdose Deaths: United States, 2010-2014. Natl Vital Stat Rep, 65(10), 1-15.

WHO. (2015). Alcohol Fact Sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs349/en/

Yudko, E., Lozhkina, O., & Fouts, A. A comprehensive review of the psychometric properties of the Drug Abuse

Screening Test. Journal of Substance Abuse Treatment, 32(2), 189-198.

https://doi.org/10.1016/j.jsat.2006.08.002

Notes

Note 1. (Bernstein et al., 2007; Bray, Kowalchuk, Waters, Laufman, & Shilling, 2012; Malone et al., 2015; Marshall

et al., 2012; M. A. Mitchell et al., 2017; Neufeld et al., 2012; Pringle, Kearney, Rickard-Aasen, Campopiano, &

Gordon, 2017; Puskar et al., 2013; Satterfield et al., 2012; Scott et al., 2012; Seale et al., 2012; Stanton, Atherton,

Toriello, & Hodgson, 2012; Tetrault et al., 2012)

Note 2. Study data were collected and managed using REDCap electronic data capture tools hosted at the University

of Vermont. REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support

data capture for research studies.

https://doi.org/10.1080/08897077.2011.640103

https://doi.org/10.1080/08897077.2011.640135

https://doi.org/10.1080/08897077.2011.640187

https://doi.org/10.3109/13561820.2014.921899

https://doi.org/10.1080/08897077.2011.640140

https://doi.org/10.1080/08897077.2011.640220

https://doi.org/10.17160/josha.4.2.290

https://doi.org/10.1016/j.jsat.2006.08.002

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